Provider Demographics
NPI:1376157032
Name:WOODLAKE ADDICTION RECOVERY OF MISSISSIPPI, LLC
Entity Type:Organization
Organization Name:WOODLAKE ADDICTION RECOVERY OF MISSISSIPPI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-900-8940
Mailing Address - Street 1:PO BOX 41853
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70835-1853
Mailing Address - Country:US
Mailing Address - Phone:225-900-8940
Mailing Address - Fax:855-532-9362
Practice Address - Street 1:152 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4409
Practice Address - Country:US
Practice Address - Phone:225-924-1910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODLAKE MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility